Yet another OBSERVATION vs. EVALUATION issue
gfrer at luna.nl
Sat Aug 18 07:10:27 EDT 2012
lets ditch the term 'Diagnosis' completely.
Or use it only when we are -as you write- scientifically certain.
And use other terms. We (EN13606 Association) prefer the 'Reasons for ...' type of terms, because that is what they do in real life.
They are the excuses to do something (or nothing); they are the cost drivers in healthcare; they must be documented.
Words like 'symptom', 'sign', 'syndrome', 'diagnosis', are fuzzy terms that can mean too many things.
We need well defined terms in our systems and standards as points of reference we agree on.
Locally all users must be allowed to use their own fuzzy terms as long as they are mapped to (and used in accordance with) the reference terms.
gfrer at luna.nl
On 18 Aug 2012, at 12:51, Karsten Hilbert wrote:
>> 20 something years of medical practice learned me to be humble and do not
>> use the word Diagnosis too lightly:
>> Example: I know that within one day I suspected the patient to have
>> shortness of breath because of: asthma, pulmonary infection, cardiac failure and
>> panic attacks/hyper ventilation. These were my inferences about the process
>> inside the patient system.
>> Only one was true and had to found out via trial and error diagnostics and
>> trial treatments. I fear that the best we can do in most circumstances (as
>> GP) is to code 'Reasons for ..' and do not use the word diagnosis too
> That's why in GNUmed there isn't even a field labelled "Diagnosis".
> We offer that field under "Assessment" (as from SOAP) and "Episode" (under
> which SOAP notes are stored). Regarding Episodes (and Health issues)
> clinical certainties thereof can be recorded:
> - sign
> - cluster of signs
> - syndromic diagnosis
> - scientifically proven diagnosis
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